Assignment 1: Practicum – Assessing Client Families
Learning Objectives
Students will:
• Assess client families presenting for psychotherapy
• Develop genograms for client families presenting for psychotherapy
To prepare:
• Select a client family that you have observed or counseled at your practicum site.
• Review pages 137–142 of Wheeler (2014) and the Hernandez Family Genogram video in this week’s Learning Resources.
• Reflect on elements of writing a comprehensive client assessment and creating a genogram for the client you selected. Assessing Client Families Essay
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The Assignment
Part 1: Comprehensive Client Family Assessment
Create a comprehensive client assessment for your selected client family that addresses (without violating HIPAA regulations) the following:
• Demographic information
• Presenting problem
• History or present illness
• Past psychiatric history
• Medical history
• Substance use history
• Developmental history
• Family psychiatric history
• Psychosocial history
• History of abuse and/or trauma
• Review of systems
• Physical assessment
• Mental status exam
• Differential diagnosis
• Case formulation
• Treatment plan
Part 2: Family Genogram
Develop a genogram for the client family you selected. The genogram should extend back at least three generations (parents, grandparents, and great grandparents).
Introduction
Comprehensive family assessment is a vital process used to assess the interactions within a family in order to identify any factor that may be adversely affecting the family, and especially the children. after a family assessment identifies factors and health issues that may be affecting the family, the proper interventions are then implemented with the goal of achieving wellness for the entire family. This paper will thus present a comprehensive family assessment conducted during practicum for a specific family. The names for the client will be anonymous in order to maintain the privacy and confidentiality of the family members, according to the HIPAA.
Demographic Information
The family consists of the father (Dan), mother (Katie), and two sons, (Sam 6-years-old & Kim 4-years-old). Dan is a 40-year-old Africa American male while Katie is a 38-year-old African American female. Dan works as a teacher in a local school while Katie is a hairdresser. Both children are school-going. Assessing Client Families Essay
Presenting Problem
An immediate neighbor made a call to fire-fighters and 911 and reported that the neighboring house was on fire and she could hear children’s cry. The children had been locked from the inside. Luckily, fire-fighters, along with the neighbors managed to put off the fire and rescue the children. The neighbor discovered that the children were in the house alone. Parents arrived 3-hours later after the children had long been rescued. They both looked visibly intoxicated. The information gathered from all the neighbors indicated that both parents had a habit of locking the children in the house alone, especially during weekend nights. The main issues surrounding this family included lack of supervision to the children. The family members further reported that both the mother and the father would drink alcohol throughout the weekend and sometimes during the weekdays and leave children unattended. Sometimes the children would be fed by the neighbors. Consequently, both Sam and Kim were placed in protective custody.
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History of Present Illness
Dan and Katie have a history of substance use. Three years ago, Dan was diagnosed with alcohol dependency and he has been interdicted several times for failure to attend his work due to alcohol intake. Katie was also diagnosed with alcohol abuse about 8 months ago. Both have been trying to quit alcohol without success. During the material day, it was on a weekend and Dan and Katie decided to go out for a few hours to take alcohol and locked their children in the house. The two children were left unattended. No one has an idea of how the fire started, but it is suspected that gas leak was the cause of the fire. They were gone for about 6-hours and the time they came back; the fire had been put off and children rescued.
Psychiatric History
Both, Dan and Katie, have substance use disorder, where both have been diagnosed with alcohol use disorder.
Medical History
Generally, all family members are in good health.
Substance use History
Dan and Katie have been diagnosed with alcohol use disorder.
Development History
Further assessment is needed
Family Psychiatric History
Dan’s mother was diagnosed with alcohol dependency while the father had bipolar II disorder. On the other hand, Katie’s mother was once diagnosed with drug abuse.
Psychosocial History
All the four-family member stay in the house. Both Dan and Katie are working. All family members are Christians. Dan and Katie are always socializing with friends during parties and drinking sprees. However, they rarely socialize with their children.
History of Abuse/Trauma
No one in the family has a history of abuse/trauma
Review of Systems
Further assessment required
Mental Status Examination
Dan and Katie have substance use disorder. Both children appear depressed and anxious.
Differential Diagnosis
Dan and Katie have alcohol use disorder which is attributable to the evident poor parenting, children neglect, and lack of supervision for the children. Lack of supervision and neglect can result in mental and physical harm as evidenced by the fire break-out while the children were alone (Syyder & Merrit, 2016). Assessing Client Families Essay
Diagnosis
- Poor parenting/inadequate children supervision
- Alcohol use disorder
Case Formulation
The family consists of the father (Dan), mother (Katie), and two sons, (Sam 6-years-old & Kim 4-years-old). A neighbor reported that the neighboring house was on fire and she could hear children’s cry. The children had been locked from the inside. Fire-fighters and the neighbors managed to put off the fire and rescue the children. Parents arrived 3-hours later after the children had long been rescued looking intoxicated. The information gathered from all the neighbors indicated that both parents had a habit of locking the children in the house alone, especially during weekend nights. The main issues surrounding this family included neglect and lack of supervision to the children (Devine, 2015). Consequently, both Sam and Kim were placed in protective custody.
Treatment Plan
Objective 1
Dan and Katie will support their children during placement
Activities
- Dan and Katie will sign the required documents
- The parents will attend all the planned visitations for their children
- Placement guardians and the parents will work in collaboration with a social worker
Objective 2
- Dan and Katie will receive therapy to quit alcohol use gradually (Conrod, 2016).
- A plan will be developed to ensure the essential supervision of the children after placement
Strategy: An action plan will be designed for Dan and Katie to address their alcohol use in order to make sure that alcohol use does not interfere with their parenting (Wheeler, 2014). This will be achieved in partnership with an experienced mental health practitioner. In addition, Dan and Katie will share the action plan with the social worker and the Children Welfare staff as well.
Social Support System
- Relatives and especially Dan’s parents and Katie’s parents
- Family friends
References
Conrod P. (2016). Personality-Targeted Interventions for Substance Use and Misuse. Curr Addict Rep. 3(4), 426–436.
Devine L. (2015). Considering the social work assessment of families. Journal of Social Welfare and Family Law. 37(1), 70-83.
Syyder S & Merrit D. (2016). The Effect of Childhood Supervisory Neglect on Emerging Adults’ Drinking. Subst Use Misuse. 51(1), 1–14.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company. Assessing Client Families Essay